Information found at National MCH Center for children Death Review: keeping kids alive

Preventing Child Deaths
Copyright Michigan Public Health Institute September 2005

The most important reason to review child deaths is to improve the health and safety of children and to prevent other children from dying.

Child Death Review team members may come to the table mostly interested in improving investigations, services or in finding those at fault for a child’s death.
Moving the focus of reviews to prevention can be a new arena for many team members and is hard work. Focusing on prevention is how your team will find meaning and purpose over the long haul. You may find that your first year or so of meetings will focus on other areas, but over time as systems improve for responding to child deaths, CDR team members will begin to ask, so now what are we going to do to prevent these deaths?
CDR is a great opportunity to mobilize persons from across your communities. Team members that might not traditionally think of themselves as prevention specialists have a lot to contribute to the design of prevention programs. For example, law enforcement knows the causes of motor vehicle crashes. The prosecutor has insight into the families involved in child abuse and neglect. The medical examiner knows the general history of the teens that die from suicide. These professionals have respect and standing in the community that can increase the chances of success of a prevention initiative.

Focusing your reviews on prevention means that your team has to act on the following: 

Determine if the Death was Preventable
The definition of preventability may vary by CDR program. The Arizona CDR program developed a definition now in use by many teams. It states that a child’s death is preventable if the community or an individual could reasonably have done something that would have changed the circumstances that led to the death.
We often think that injury events are random "accidents.” However, most injuries to children are predictable, understandable and therefore preventable.
You will probably focus prevention efforts on manners of death we usually think of as preventable: accidents, homicides and suicides. CDR teams should also consider risk factors that can be addressed to prevent natural deaths. For example, it is estimated that one-half of all perinatal deaths could be prevented if attention had been paid to factors related to maternal health in the prenatal period. We also now know that there are factors that can reduce the risks of a SIDS death, including sleeping position, smoking and overheating. For deaths due to medical conditions, your team may discuss the availability and adequacy of health care, compliance with medical treatment regimens and barriers to persons seeking or obtaining quality care.
Identify Modifiable Risk Factors
Reviewing the circumstances of each death helps teams focus on the specific factors that caused the death or made the child more susceptible to harm. Once the team has identified these factors, the team should decide which factors they believe they can modify or impact. Not all risk factors are easy to impact; some may require long term, systemic change. Thus, the prevention of risk may be easy or it may be complicated and long term.
Once you know the risk factors, it is also important that you assess the extent of the problem and who it most impacts. You may want to focus your prevention strategies on certain populations of children to have the most impact. To do this:
•               Collect information to know where and how often the types of deaths and related injuries occur. Obtain morbidity data to understand the full extent of the problem. For example, you may have reviewed one suicide, but further analysis of the number of teens who seek services at your local hospital emergency room for suicide attempts will help you to understand the full extent of the risks.
•               Determine then which children are most at risk and why.


Determine the Best Strategy(ies) for Prevention
There are numerous frameworks you can use to determine the best strategy for prevention. For example, the field of injury has identified the Four E’s: impacting education, engineering, enactment and enforcement.

The Spectrum of Prevention is a model that your team can use to create longlasting, positive changes in the community. The Spectrum of Prevention describes seven levels at which prevention activities can take place, and moves beyond individual services and community education.  It encourages creative and effective prevention projects and can help communities develop activities that are likely to be more successful since they complement the prevention efforts that already exist within a community.
Identify Specific Prevention Activities
Regardless of the model you use to identify your key prevention strategies, you will then need to identify what specific activities need to be implemented.
To determine the specific prevention strategies, your team should review the prevention literature to make sure your recommendations have been proven to be effective. This means that they have been implemented, evaluated and preferably published in a peer-reviewed journal. Try to select interventions that have demonstrated efficacy and are appropriate to your community.
A number of websites can help you identify proven strategies. For example, injury prevention strategies can be found at the Harborview Injury Prevention Research Center web site:
To identify the best prevention strategies and activities, teams should weigh the following:
•               Effectiveness
•               Ease of implementation
•               Cost
•               Sustainability
•               Community acceptance
•               Political reality
•               Unintended Consequences
Even with a desire to take action, there are some other things that have to be kept in mind when planning prevention:
•               Don't reinvent the wheel. Prevention programs have been developed and implemented throughout the country. In researching prevention activity outcomes, you can learn from others' mistakes and build on what has been successful elsewhere.
•               Don’t look for nor expect quick and easy long-term solutions. The situations that lead to child deaths are complex. Prevention programs take time and effort to design and implement and often even more time to impact the lives of children. Moreover, the changes that occur most likely will permanently require consistent attention at some level.
•               Prevention research has shown that combinations of strategies and activities will be more effective than any one single activity.
Effective Prevention Strategies by Type of Death
Take Action or Share Your Findings to Ensure that Action will be Take n
Teams do not have to implement their proposed prevention strategies and activities, but the team should make sure they follow through to make sure that someone or some agency has assumed responsibility. The team can serve to foster accountability as well as recognize and reward community efforts. It is important that your team:
•               Identifies someone willing to take the lead.
•               Identifies resources.
•               Identifies someone to follow-up and report back to the team.
•               Provides recognition to those implementing the CDR recommendations.
The multidisciplinary nature of CDR provides a powerful platform to make a difference. As previously mentioned the team can be an effective catalyst for change while fostering accountability and recognizing and rewarding community efforts. Scarce resources require sharing of findings and recommendations to be strategic.

Your findings should be shared, along with your written recommendations, with the appropriate agencies or individuals that are best positioned to take action. If you are a local team, you can send your recommendations to local agencies for local action. You can send them to the state, which can then use them to advocate for or develop state-level prevention actions. Many state teams have recommendations in their reports to the legislature, government agencies and the public. The following is a list of possible recipients:
•               Local CDR team member(s).
•               State CDR team(s).
•               The media.
•               Professionals.
•               Academics/educators.
•               State organizations (AAP, ACOG, SAFE KIDS, etc.).
•               State Agencies (child protection, public health, public safety and others)
•               Community leaders.
•               Parents/teachers/student organizations.
•               Not for profit organizations.
•               Fundraising groups.
•               Civic organizations.
In sharing your findings, choose an appropriate forum, such as
•               Formal presentations.
•               Formal letters to agencies.
•               Radio, television, newspaper, newsletter.
•               Public service announcements.
•               Annual reports or summary reports.
Use the stature of individual team members to help advocate for your recommendations. For example, your district attorney may have political influence with a state legislator or be a popular elected official and able to garner support from the general public.
Good leadership is essential for successful prevention activities. The leader does not have to be the team chair or coordinator and the leader does not have to be the same for every prevention effort. Leaders do not even have to be individuals. They can be the entire team, a sub-committee of a team or persons not even on the team.
Good leaders share some traits. They are:
•               Able to inspire others and maintain enthusiasm.
•               Able to provide coordination.
•               Able to access data and connect with decision makers.
•               Sensitive to political realities.
•               Collaborators.
Write Effective Recommendations
The very best prevention ideas that result from your reviews can go to naught, unless you develop well-written recommendations. Your team should put in writing the findings that led your team to identifying the need for prevention, the strategies and activities that will address the risk factors and the plan to insure they are implemented. While the core of a written recommendation can be a simple statement, an effective recommendation should have three important components. This will help ensure that your recommendations will be understood, adopted and implemented:
1.             Your assessment of the type of deaths you are trying to prevent.
2.             Your action-oriented recommendation.
3.             Your plans to follow-up on the recommendation.
By putting your ideas in writing, your team will be able to better monitor and track how your recommendations are implemented.

Your recommendation should be as specific as possible. For example, a recommendation that “newly licensed teen drivers should not have other teen passengers in the car during their first month of licensure” is an important objective, but is not an effective recommendation. It doesn’t address how you will accomplish the objective and is not action oriented.

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